Ann Agric Environ Med.
2013; Special Issue 1: 28–34
www.aaem.pl
Pain management in children
Artur Mazur1, Igor Radziewicz Winnicki2, Tomasz Szczepański3
1
Medical Faculty University of Rzeszów, Poland
2
Medical University of Silesia, School of Health Sciences, Katowice, Poland
3
Department of Pediatric Hematology and Oncology, Medical University of Silesia, Katowice, Poland
Mazur A, Radziewicz Winnicki I, Szczepański T. Pain management in children. Ann Agric Environ Med. 2013; Special Issue: 28–34.
Abstract
The paediatric population is at risk of inadequate pain management, with age-related factors affecting pain management
in children. This presented study discusses the complexities of measuring paediatric pain, reviews the most well-known
pain assessment scales, and emphasizes the importance of family involvement in situations where children are asked to
self-report their experiences. Current recommendations for treatment of pain in children are critically reviewed.
Key words
pain, children, pain management
INTRODUCTION
According to the International Association for the Study of
Pain (IASP), pain is defined as ‘an unpleasant sensory and
emotional experience associated with actual or potential
tissue damage or described in terms of such damage’ [1]. It
is important to stress that pain encompasses both peripheral
physiologic and central cognitive/emotional components and
may or may not be associated with real tissue damage. Pain
may exist in the absence of demonstrable somatic pathology.
The assessment of pain, therefore, relies largely upon the use
of self-report. An even more difficult and complex issue is
the identification, measurment, and effective treatment of
pain in children [2].
Categories of paediatric pain. Typically, paediatric pain can
be divided into three major categories, i.e.: somatic, visceral
and neuropathic [3]. Somatic pain is caused by tissue injury
or inflammation. Typical examples of somatic pain include
burns, fractures, infections, and various inflammatory
conditions. When involving skin and superficial structures,
somatic pain is sharp and well-localized. Visceral pain is
caused by inflammation or injury of internal organs (viscera),
usually poorly localized or referred to distant locations.
Typical examples include appendicitis, rapidly increasing
hepatomegaly, bowel distension or gastritis. Finally,
neuropathic pain is caused by injury, inflammation, or
dysfunction of the peripheral or central nervous systems,
e.g. associated with phantom limb pain, Guillain-Barré
syndrome, sciatica, etc.
Pain from the public health perspective. Pain among
children and adolescents has been identified as an important
public health problem, although little is known about the
epidemiology of pain in children. It is estimated that 15–
25% of children and adolescents suffer from recurrent or
chronic pain. More than 50% of them have experienced a
pain episode within the previous 3 months. The prevalence
of chronic pain increases with age, and is more common in
girls than boys. Girls are significantly more likely to report
Address for correspondence: Artur Mazur, Medical Faculty University of Rzeszów,
Poland
e-mail: drmazur@poczta.onet.pl
Received: 30 October 2013; accepted: 29 December 2013
REVIEW ARTICLE
multiple health complaints. This tendency was also shown in
international studies and proved in almost all countries and
regions [4, 5, 6, 7]. Gender differences in prevalence increase
with age. In the majority of countries and regions, girls at the
age of 15 present a more than 10% higher burden of health
complaints than boys. The most common types of complaints
are abdominal pains, musculoskeletal pain, and headaches.
Health complaints of somatic performance and psychological
symptoms, e.g. nervousness or irritability, tend to occur
together. Episodes of pain impact on school performance and
peer relations. Recurrent pain is a reason for more than a half
of short-period (1–6 days) school absences. Children with
recurrent pains are at risk to develop additional physical and
mental problems, such as functional disorders and anxiety
in adulthood. 25–50% of patients with recurrent functional
pains in adolescence continue to suffer from this condition
in adulthood. Approximately 35% of patients with recurrent
pains in childhood develop some psychiatric problems in
adulthood [8, 9, 10].
The burden of frequent stress imposes the development of
pain complaints. There is much evidence for the association of
recurrent pain with family conflicts, experience of violence,
bullying, lack of acceptance by peers, and lack of proper
support from parents and teachers. In an HBSC study, school
has been identified as a protective factor against multiple
health complaints. However, low perceived classmate support
is related to presentation of headaches and abdominal pains.
The presence of recurrent pains in adolescents varies within
the social gradient. The family lack of affluence, especially
the poor social status predicts more risk of development of
pains [4, 11, 12, 13].
Recurrent pain in children is also one of most common
reasons for paediatric consultations. However, recurrent
pains are in the majority of benign causation, they result in
additional diagnostics, specialist consultations, which may
elevate anxiety and impression of suffering from a serious
condition. In turn, differential diagnostics of recurrent pains
may immensely elevate stress in children and parents and
aggravate symptoms. There is a need to seek an organic
background for the causes of pain, with its increased health
expenditure and overtreatment.
Pain assessment. Until recently, many believed that neonates
experienced no pain or less pain than adults, children, or
Ann Agric Environ Med. 2013; Special Issue 1
Artur Mazur, Igor Radziewicz Winnicki, Tomasz Szczepański. Pain management in children
infants who underwent similar surgical procedures. However,
only within the last two decades medical professionals has
realized that all paediatric patients, including neonates, also
feel pain and require relevant medical intervention [2, 3].
There is no consensus of opinion about when a foetus begins
to experience pain. Most opinions range from 26 – 30 weeks
of gestation [4]. Van de Velde and de Buck [5] have described
that the peripheral receptors develop from the 7th gestational
week, and from 20 weeks’ gestation peripheral receptors are
present in the whole body. In their opinion, the development
of afferent fibres connecting peripheral receptors with the
dorsal horn starts at 8 weeks’ gestation, while thalamocortical
connections are present from 17 weeks’ and are completely
developed at 26–30 weeks’ gestation [5].
Gupta et al. [6] suggest that probably the brain stem in
early gestation may perform some neurological functions
that are subsequently subsumed by the cortex. During early
gestation, the foetus reacts to stimuli to pain receptors
in various ways.  In some studies, foetal stress responses
have been detected; however, this needs further research
to define its significance. Stress reduction is certainly
beneficial for children, and the same would presumably
apply to foetuses; this may well have implications for foetal
surgery [7, 8]. Perhaps, with the mother’s consent, foetuses at
risk of experiencing pain should be given appropriate doses
of regional anaesthesia or analgesia, according to clinical
circumstances [8, 9].
There is no evidence to support the view that pain is
less intense in neonates and young children due to their
developing nervous system [2]. On the other hand, pain is
subjective and the pain response is individual and modified
through various experiences during life [2, 9]. Some studies
suggests that childhood pain response is more intense at
the beginning and diminishes much earlier than in adults
[2, 10]. Because the etiology of childhood pain is also highly
emotional, therefore the understanding and help of parents
are very required [11].
Pain means significant stress in all paediatric patients,
and is associated with an inferior medical outcome. Young
infants who during surgery received inadequate treatment
for pain, produce enormous amounts of stress hormones,
which results in increased catabolism, immunosuppression
and haemodynamic instability [3, 12]. Thus, younger children
may even experience higher levels of distress during painful
procedures that older children, because they tend to cope
with pain more behaviourally [3, 12].
Pawar and Garten [2] have described developmental
differences of pain expression in such various paediatric
age groups:
• Infants – may exhibit body rigidity, may include arching,
exhibit facial expression (brows lowered and drawn
together, eyes tightly closed, mouth open and squarish),
cry intensely/loudly, draw knees to chest, exhibit
hypersensitivity or irritability, have poor oral intake, or
be unable to sleep.
• Toddlers – may be verbally aggressive, cry intensely,
exhibit regressive behaviour or withdraw, exhibit physical
resistance by pushing painful stimulus away after it is
applied, guard painful area of body, or be unable to sleep.
• Preschoolers – may verbalize intensity of pain, see pain as
punishment, exhibit thrashing of arms and legs, attempt to
push a stimulus away before it is applied, be uncooperative,
need physical restraint, cling to a parent, nurse, or other
29
guardian, request emotional support, understand that
there can be secondary gains associated with pain, or be
unable to sleep.
• School-age children – may verbalize pain, use an objective
measurement of pain, be influenced by cultural beliefs,
experience nightmares related to pain, exhibit stalling
behaviours, have muscular rigidity, e.g. clenched fists,
white knuckles, gritted teeth, contracted limbs; exhibit
body stiffness, closed eyes, wrinkled forehead, engage
in the same behaviours listed for pre-schoolers/young
children, or be unable to sleep.
• Adolescents – may localize and verbalize pain, deny pain
in the presence of peers, have changes in sleep patterns or
appetite, be influenced by cultural beliefs, exhibit muscle
tension and body control, display regressive behaviour in
the presence of the family, or be unable to sleep.
Age-specific and developmentally specific measures.
Because infants, young children, and non-verbal children
cannot express the quantity of pain they experience, several
pain scales have been devised in an attempt to quantify pain
in these populations [14, 15]
Newborn and infant. A range of behavioural distress scales
were developed for the newborn and infant were, mostly
emphasizing the patient’s facial expressions, crying, and
body movement. Facial expression measures appear most
useful and specific in neonates. Typical facial signs of pain
and physical distress in infants are: eyebrows lowered and
drawn together, a bulge between the eyebrows and vertical
furrows on the forehead, eyes slightly closed, cheeks raised,
nose broadened and bulging, deepened nasolabial fold, open
and squarish mouth [2, 3, 10]. Autonomic and vital signs
can indicate pain, but because they are nonspecific, they
may reflect other processes, including fever, hypoxaemia,
and cardiac or renal dysfunction [2, 3, 12, 13]. The most
commonly used scales in newborns are the Premature
Infant Pain Profile (PIPP) and the CRIES Postoperative
Pain Scales [16–18]. The FLACC (Face, Legs, Activity, Cry
and Consolability) Scale is a behavioural scale that has been
validated for assessment of postoperative pain in children
between the ages of 2 months and 7 years [19].
After observing a child for one to five minutes, a pain score
is obtained by reviewing the descriptions of behaviour and
selecting the number that most closely matches the observed
behaviour.
Pre-school infants. Children 3–6  years old become
increasingly articulate in describing the intensity, location,
and quality of pain. Pain is occasionally referred to adjacent
areas; referral of hip pain to the leg or knee is common in
this age range. Self-report measures for children this age
include using drawings, pictures of faces, or graded colour
intensities [2, 3, 13, 20].
Well established self-report pain scales developed for
young children include the Poker Chip Scale, Wong-Baker
Faces Scale (free to use), the Faces Pain Scale-Revised (FPS-R)
and the Oucher Scale [20, 21, 22, 23, 24, 25] The FPS-R has
been translated into more than 30 languages and is also free
to use [21]. The Oucher Scale, available in different ethnic
versions, permits children to rate their pain intensity by
matching it to photographs of other children’s faces depicting
increasing levels of pain, and is well accepted in children over
30
Artur Mazur, Igor Radziewicz Winnicki, Tomasz Szczepański. Pain management in children
6 years of age [3, 25, 26, 27, 28, 29]. The Poker Chip Scale asks
children to quantify their pain in ‘pieces of hurt’, with more
poker chips representing more pain. Body outlines allow
young children to point to the location of their pain. The
Poker Chip Tool appears to have the most utility as a simple
clinical assessment tool to identify presence/absence of pain
and general estimates of pain intensity in young children
[3, 29, 30, 31, 32, 33, 34, 35, 36].
School-children and adolescents. In this age group,
children can usually use verbal scales or visual analog pain
scales (VASs) accurately. The VASs is the gold standard
for assessment of pain in adults. The traditional scale is a
10cm scale with markings at 1  cm intervals from 0 – 10.
Zero denotes ‘no pain’ and 10 denotes ‘excruciating pain’.
The patient is asked to identify the mark on the scale that
corresponds to his/her degree of pain. The Numerical Rating
Scale (NRS) consists of numbers from 0 – 10, in which 0
represents no pain and 10 represents very severe pain. This
scales valid and reliable ratings are for children of 8 years
and older. There is debate about the label for the highest pain
rating, but the current agreement is not to use the worst pain
possible, because children can always imagine a greater pain.
Pain scores do not always correlate with changes in heart rate
or blood pressure [31, 32, 33, 34, 35, 36, 37, 38, 39].
Cognitively impaired children. Measuring pain in cognitively
impaired children remains very difficult. Understanding pain
expression and experience in this population is important,
because behaviours may be misinterpreted as indicating
that cognitively impaired children are more insensitive to
pain than cognitively competent children. Hennequin et al
[40] stated that Down syndrome children may express pain
less precisely and more slowly than the general population,
whereas Bandstra et al [42] reported that pain in children
with autism spectrum disorders may be difficult to assess
because they may be both hyposensitive and hypersensitive
to many different types of sensory stimuli, and they may have
limited communication abilities. Self-reports of pain can be
elicited from some children who are cognitively impaired,
observational measures have better validation among these
children. For assessment pain for this group of children the
Non-communicating Child’s Pain Checklist – Postoperative
Version is recommended. Maladaptive behaviour and
reduction in functions may also indicate pain. Children with
severe cognitive impairments experience pain frequently,
mostly not because of accidental injury. Children with the
fewest abilities experience the most pain [3, 42].
Paediatric pain management. Pain management in children
should follow the WHO analgesic stepladder (‘be the ladder’),
be administered on a scheduled basis (‘by the clock’), because
‘on demand’ often means ‘not given’), be given by the least
invasive route (‘be the mouth’), and tailored to the individual
child’s circumstance and needs (‘be the child’) [43]. Although
there is a limited number of analgesic medicines that can
be safely used in children, the WHO recommends in its last
guidelines the provision of adequate analgesia with a two-
step approach. This two-step strategy consists of a choice
of category of analgesic medicines according to the child’s
level of pain severity: for children assessed as having mild
pain, paracetamol and ibuprofen should be considered as
first options, and in children assessed as being in moderate
Ann Agric Environ Med. 2013; Special Issue 1
to severe pain, the administration of an opioid should be
considered [43]. Both pharmacologic and non-pharmacologic
approaches to pain management should be considered for all
pain treatment plans. Many simple interventions designed
to promote relaxation and patient control can be expected to
work synergistically with pain medications for optimal relief
of pain and related distress. Psychological and developmental
comorbidities affect the child’s experience of pain and ability
to tolerate and cope with it. Therefore, it is important to assess
a child for evidence of situational anxiety and/or anxiety
disorders. All psychological and developmental comorbidities
should be determined and addressed, to adequately treat the
child in pain or to reduce the risk of the child’s developing
ongoing pain after surgery, trauma, or even invasive medical
procedures [4, 11, 13]. Therefore, in many paediatric centres,
special paediatric pain services have been established [44, 45]
Non-pharmacological methods which can be used to
relieve pain, fear, and anxiety in children [43]:
• emotional support (parents should be with their child
during any painful procedures);
• physical methods (relaxation techniques promote muscle
relaxation and reduction of anxiety, biofeedback, massage
therapy, physical therapy,acupuncture, Transcutaneous
electrical nerve stimulation (TENS);
• cognitive methods (distraction, such as singing or reading
to the child, play activities, or imagining a pleasant place);
• hypnotherapy;
• prayer (the family’s practice must be respected);
• other traditional practices that could be helpful and not
harmful.
Children and family members should receive proper
information about the mechanisms and appropriate treatment
of pain, to help them better cope with the situation and
increase better compliance. Health professionals should still
remember that the methods described above are ‘additionals’,
and should not be used in place of analgesic medications
when they are necessary [4, 11, 13].
Pharmacologic treatment of pain
Considerations in treating infants and children. During the
treating of pain in infants it is important to understand that
although most of the major organ systems are anatomically
well developed at birth, their functional maturity is often
delayed. In the first months of life, in both preterm and
full-term newborns, these systems rapidly mature, most
approaching a functional level similar to adults before 3
months of age [46, 47].
The pharmacokinetics and pharmacodynamics of
analgesics vary with age; drug responses in infants and young
children differ from those in older children and adults. The
elimination half-life of most analgesics is prolonged in
neonates and young infants because of their immature
hepatic enzyme systems [46, 47, 48, 49, 50]. Tayman et al.
[25] described that the clearance of analgesics may also be
variable in young infants and children because development
of renal function is incomplete: nephrons begin forming
in utero at 9 weeks, formation is complete at 36 weeks, but
functionally immature, GFR have a range of only ½ of adult
values at birth, tubular secretion rate is only 20% of adult
capacity. A less frequent dosing interval is needed to avoid
accumulation and toxicity; however, poor renal elimination
is more often the result of disease or hydration status. Age-
Ann Agric Environ Med. 2013; Special Issue 1
Artur Mazur, Igor Radziewicz Winnicki, Tomasz Szczepański. Pain management in children
related differences in body composition and protein binding
also exist. Newborns have a higher percentage of body
weight as water and less as fat compared with older patients.
Water soluble drugs, therefore, often have larger volumes of
distribution [17, 18, 19]. Newborns, and especially premature
infants, have diminished ventilatory responses to hypoxaemia
and hypercapnia [18, 19] These ventilatory responses can be
further impaired by CNS depressant drugs such as opioids
and benzodiazepines [18, 19]. Except in the newborn period,
when the half-life after administration is significantly
longer, the pharmacodynamics and pharmacokinetics of
nonsteroidal anti-inflammatory drugs (NSAIDs) in children
are not much different than in adults [18, 19, 25]. However, the
potential for gastrointestinal (GI), renal and other toxicities
exist, but the incidence of these problems in young and older
children may be less than that encountered during treatment
of adults, perhaps due to the uncommon occurrence of
the comorbidities and polypragmasia that predispose to
problems [18, 19, 25].
Opioids are an essential element in pain management.
There is no other class of medicines that is effective in the
treatment of moderate and severe pain. The WHO supported
the inclusion of morphine in the WHO model list of essential
medicines for children to substantiate its use in children to
relieve moderate to severe pain [50].
In the newborn’s age, the elimination half-life of morphine
is more than twice as long as that in older children and
adults, as a result of delayed clearance [12]. Annand et al. [51]
suggest that this appears to be due to several factors, the most
important of which is the immaturity of the newborn infant’s
hepatic enzyme systems. Clearance of morphine is dependent
on conjugation of the drug to form the metabolites morphine-
3-glucuronide and morphine-6-glucuronide and the latter
contributes a substantial fraction of morphine’s analgesic
effects. Tayman et al. [25] emphasized the role of glomerular
filtration, which is reduced in the first week of life and leads
to slower elimination of morphine’s active metabolites.
These pharmacokinetic differences between neonates
and older children must be understood to adjust dosing
appropriately and avoid toxicity. Equally important in
determining safe opioid dosing in infants is an understanding
of the immaturity of the central respiratory control
mechanisms [40, 50, 52, 53]. Infants in the first 3 – 6 months
of life have inadequate and sometime paradoxical ventilatory
responses to both hypoxia and hypercapnia, which can
cause the development of apnea, or periodic breathing, after
receiving even small doses of opioids [18, 19, 25].
Cardiorespiratory monitoring and careful observation is
recommended whenever opioids are administered to infants
less than 2 – 3 months of age. Premature infants and former
premature infants with chronic lung disease continue to show
depressed hypoxic drive for several months, and often require
careful monitoring after opioid administration up to 5 – 6
months of age. Optimal use of opioids requires proactive
and anticipatory management of side effects [50, 53, 54, 55].
WHO recommendations. Current WHO recommendations
for the correct use of analgesic medicines in children relies
on the following key concepts [43, 50]:
• using a two-step strategy;
• dosing at regular intervals;
• using the appropriate route of administration;
• adapting treatment to the individual child.
31
The WHO two-step strategy consists of a choice of category
of analgesic medicines according to the child’s level of
pain severity: for children assessed as having mild pain,
paracetamol and ibuprofen should be considered as first
options; for children assessed as being in moderate to severe
pain, the administration of an opioid should be considered.
In children above three months of age who can take
oral medication and whose pain is assessed as being mild,
paracetamol and ibuprofen are the medicines of choice.
For children below three months of age, the only option
is paracetamol. No other non-steroidal anti-inflammatory
drug (NSAID) has been sufficiently studied in paediatrics
for efficacy and safety to be recommended as an alternative
to ibuprofen. Although there is evidence of the superior
analgesic properties of ibuprofen versus paracetamol in acute
pain, this is considered low-quality evidence because studies
were performed in acute pain settings, and because of the
absence of long-term safety evidence for its continuous use
in persisting pain [43, 50].
Table 1 shows on-opioid analgesics for the relief of pain in
neonates, infants and children recommended by WHO
[43, 50]. According to WHO recommendations, medicines
should be administered to children by the simplest, most
effective, and least painful route, making oral formulations
the most convenient and the least expensive route of
administration [43, 50]. The choice of alternative routes of
administration, such as intravenous (IV), subcutaneous (SC),
rectal or transdermal when the oral route is not available,
should be based on clinical judgment, availability, and patient
preference. The intramuscular (IM) route of administration
is painful and is to be avoided. The rectal route has an
unreliable bioavailability, both for paracetamol and
morphine, which  limits its applicability [43,  50]. The
feasibility of employing different routes of administration
depends on the setting.
Table 1. Opioid analgesics for the relief of pain in neonates, infants and
children recommended by WHO [43]
Dose (oral route)
Infants from 3
Neonates Infants from
to 12 months or Maximum daily
Medicine from 0 30 days to
to 29 days 3 months
child from 1 to dose
12 years
5–10 mg/kg 10 mg/kg 10–15 mg/kg Neonates, infants
Paracetamol every every 4–6 every and children:
6–8 hours a hours a 4–6 hours a,b 4 doses/day
Ibuprofen
5–10 mg/kg Child:
every 6–8 hours 40 mg/kg/day
a Children who are malnourished or in a poor nutritional state are more likely to be susceptible
to toxicity at
standard dose regimens due to reduced natural detoxifying glutathione enzyme.
b Maximum of 1 gram at a time.
Opioid analgesics. The use of strong opioid analgesics is
recommended by the WHO for the relief of moderate to
severe persisting pain in children with medical illnesses
[50]. The opioid dose that effectively relieves pain varies
widely between children, and in the same child at different
times, and therefore should be based on the child’s pain
severity assessment. Large opioid doses given at frequent
intervals may be necessary to control pain in some children;
these doses may be regarded as appropriate, provided that
the side-effects are minimal or can be managed with other
medicines [50]. An alternative opioid should be tried if
32 Ann Agric Environ Med. 2013; Special Issue 1
Artur Mazur, Igor Radziewicz Winnicki, Tomasz Szczepański. Pain management in children

patients experience unacceptable side-effects such as nausea, Table 4. Starting dosages for opioid analgesics in opioid-naive children
vomiting, sedation and confusion [3, 50, 51, 52, 53]. The most (1–12 years) according to WHO recommendations [43]
common, troubling but treatable side-effect is constipation. Route od
Medicine Starting dose
Constipation also remains a problem with long-term opioid Administration
administration. A peripherally acting opiate µ receptor 1–2 years: 200–400 mcg/kg every 4 hours
Oral (immediate
antagonist, methylnaltrexone, promptly and effectively release)
2–12 years: 200–500 mcg/kg every 4 hours
reverses opioid-induced constipation in patients with chronic (max 5 mg)
pain who are receiving opioids daily. The side-effect of Oral (prolonged
200–800 mcg/kg every 12 hours
nausea typically subsides with long-term dosing, but it may release)
require treatment with anti-emetics, such as a phenothiazine, Morphine IV injectiona 1–2 years: 100 mcg/kg every 4 hours
butyrophenones, antihistamines, or a serotonin receptor 2–12 years: 100–200 mcg/kg every 4 hours
SC injection (max 2.5 mg
antagonist, such as ondansetron or granisetron. Pruritus
and other complications during patient-controlled analgesia IV Infusion
initial IV dose : 100–200mcg/kga,
(PCA) with opioids may be effectively managed by a low-dose then 20–30 mcg/kg/hour

IV naloxone [53, 54, 55]. SC infusion 20 mcg/kg/hour

There is no upper dosage limit for opioid analgesics because IV injection 1–2 mcg/kgb, repeated every 30–60 minutes
there is no ‘ceiling’ analgesic effect. The appropriate dose is Fentanyl
IV infusion Initial IV dose 1–2 mcg/kgb, then 1 mcg/kg/hour
the dose that produces pain relief for the individual child. The
Oral (immediate 30–80 mcg/kg every 3–4 hours
goal of titration to pain relief is to select a dose that prevents release) (max 2 mg/dose)
Hydro­
the child from experiencing pain between two doses using morphonec IV injectiond
the lowest effective dose. or SC injection
15 mcg/kg every 3–6 hours
The starting dose of opioids according to the WHO
Oral (immediate
recommendations is shown in Tables 2, 3, 4, 5 [43, 50]. release) 100–200 mcg/kg
Methadonee every 4 hoursfor the first 2–3 doses,
IV injectiong
then every 6–12 hours(max 5 mg/dose initially)f
Table 2. Recommended by WHO starting dosages for opioid analgesics and SC injection
for opioid-naive neonates [43]
Oral (immediate
Route od 125–200 mcg/kg every 4 hours(max 5 mg/dose)
release)
Medicine Adminis­ Starting dose Oxycodone
tration Oral (prolonged
5 mg every 12 hours
release)
IV injectiona a
25–50 mcg/kg every 6 hours Administer IV morphine slowly over at least 5 minutes.
SC injection b
Administer IV fentanylslowly over 3–5 minutes.
Morphine c
Hydromorphone is a potent opioid and significant differences exist between oral and
Initial IV doseaa 25–50 mcg/kg, then 5–10 mcg/kg/hour intravenous dosing. Useextreme caution when converting from one route to another. In
IV infusion converting from parenteral hydromorphone to oralhydromorphone, doses may need to be
100 mcg/kg every 6 or 4 hours
titrated up to 5 timesthe IV dose.
d
IV injection 1–2 mcg/kg every 2–4 hours Administer IV hydromorphone slowly over 2–3 minutes.
Fentanylb e
Due to the complex nature and wide inter-individual variation in the pharmacokinetics of
IV infusion Initial IV dosec 1–2 mcg/kg, then 0.5–1 mcg/kg/hour methadone, methadoneshould only be commenced by practitioners experienced with its use.
f
Methadone should initially be titrated like otherstrong opioids.The dosage may need to be
a
Administer IV morphine slowly over at least 5 minutes. reduced by 50%2–3 days after the effective dose has been found to prevent adverse effects due
b
The intravenous doses for neonates are based on acute pain management and sedation dosing to methadone accumulation.From then on dosage increasesshould be performed at intervals
information. Lower doses are required for non-ventilated neonates. of one week or over and with a maximum increaseof 50%.
c
Administer IV fentanyl slowly over 3–5 minutes g
Administer IV methadone slowly over 3–5 minutes.

Table 3. Starting dosages for opioid analgesics in opioid-naive infants Table 5. Approximate dose ratios for switching between parenteral and
(1 month – 1 year) according WHO recommendations [43] oral dosage forms [43]
Route od Adminis­ Medicine Dose ratio (parenteral : oral)
Medicine Starting dose
tration
Morphine 1:2 – 1:3
Oral (immediate
80–200 mcg/kg every 4 hours Hydromorphone 1:2 – 1:5a
release)
Methadone 1:1 – 1:2
IV injectiona 1–6 months: 100 mcg/kg every 6 hours
a
6–12 months: 100 mcg/kg every 4 hours Hydromorphone is a potent opioid and significant differences exist between oral and
SC injection (max 2.5 mg /dose) intravenous dosing. Useextreme caution when converting from one route to another. In
converting from parenteral hydromorphone to oralhydromorphone, doses may need to be
Morphine 1–6 months: Initial IV dose: 50 mcg/kg, titrated up to 5 timesthe IV dose.
then: 10–30 mcg/kg/hour
IV infusion a
6–12 months: Initial IV dose: 100–200 mcg/kg, WHO guidance after a starting dose – the dosage should
then: 20–30 mcg/kg/hour
be adjusted on an individual basis to the level at which it is
1–3 months: 10 mcg/kg/hour effective (with no maximum dose, unless further increase is
SC infusion
3–12 months: 20 mcg/kg/hour
not possible, because of untreatable side-effects) [43, 50]. The
IV injection 1–2 mcg/kg every 2–4 hoursc maximum dosage increase is 50% per 24 hours in outpatient
Fentanyl settings. Experienced prescribers can increase up to 100%
b
Initial IV dose 1–2 mcg/kgc,
IV infusion
then 0.5–1 mcg/kg/hour while monitoring the patient carefully [43, 50]. Morphine is
Oxycodone
Oral (immediate
50–125 mcg/kg every 4 hours
recommended as the first-line strong opioid for the treatment
release) of persisting moderate to severe pain in children with medical
a
b
Administer IV morphine slowly over at least 5 minutes. illnesses.
The intravenous doses of fentanyl for infants are based on acute pain management and
sedation dosing information. There is insufficient evidence to recommend any alternative
c
Administer IV fentanylslowly over 3–5 minutes. opioid in preference to morphine as the opioid of first choice.
Ann Agric Environ Med. 2013; Special Issue 1
Artur Mazur, Igor Radziewicz Winnicki, Tomasz Szczepański. Pain management in children
Selection of alternative opioid analgesics to morphine should
be guided by considerations of safety, availability, cost and
suitability, including patient-related factors. Switching
opioids and/or route of administration in children is strongly
recommended in the presence of inadequate analgesic effect
with intolerable side-effects. Alternative opioids and/or
dosage forms as an alternative to oral morphine should,
if possible, be available to practitioners, in addition to
morphine. Routine rotation of opioids is not recommended
[43, 50].
Continuous IV infusion of opioids is one effective option
that permits more constant plasma concentrations and
clinical effects than intermittent IV bolus dosing, without
the pain associated with intramuscular injection [30]. The
most common approach in paediatric centres is to administer
a low-dose basal opioid infusion, while permitting patients
to use a patient-controlled analgesia (PCA) device to titrate
the dosage above the infusion. Using this method, dosing can
be adjusted to account for individual pharmacokinetic and
pharmacodynamic variation and for changing pain intensity
during the day; psychologically, the patient is more in control,
actively coping with the pain, overall opioid consumption
is lower, fewer side- effects occur, and patient satisfaction is
generally much higher. Children as young as 5–6 years can
effectively use PCA [53, 54, 55].
Children who have chronic pain related to cancer or other
serious illness can be treated with long-term opioid therapy,
typically with oral or transdermal delivery. The guidelines
to optimize outcomes mirror those for adults [53, 54, 55].
If opioid analgesics are suddenly withdrawn, children
display neurological signs, such as irritability, anxiety,
insomnia, agitation, increased muscle tone, and abnormal
tremors, and experience gastrointestinal symptoms, such
as nausea, vomiting, abdominal cramps, diarrhea and poor
appetite. In children, other withdrawal syndrome symptoms
can also be observed, such as tachypnea, tachycardia, fever,
sweating and hypertension [43, 49, 50, 51]. In children who
have received significant doses of opioid analgesics for a
long time there is an increased risk for the development
of withdrawal syndrome. From the medical standpoint,
weaning opioids should be done slowly by tapering the opioid
dose. For short-term therapy (7–14 days), the original dose
can be decreased by 10–20% of the original dose every 8
hours, and gradually increasing the time interval. In the
case of a long-term therapy protocol, the dose should be
reduced not more than 10–20% per week [43,  50]. These
pharmacological approaches should be accompanied by
measurement of withdrawal symptoms using a special
scoring system [43, 50].
CONCLUSIONS
Children of all ages should receive effective pain treatment.
Analgesics should be used in effective doses, and should not be
limited to medical therapies alone. Healthcare practitioners
should recognize that pain treatment and prevention is
essential even when children are too young or cognitively
unable to report the extent and severity of their pain.
33
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